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Changing practice for neuraxial applications using NRFit™ small-bore connectors to improve patient safety

25 February 2021
13 min read
Volume 30 · Issue 4

Abstract

Clinical staff always aim to offer the best care for their patients while striving to minimise the risk of errors. The worldwide adoption of the NRFit™ system for neuraxial and regional block procedures is a major step forward. This article discusses the history of neuraxial needles and the experience of a major teaching hospital in adopting non-luer equipment for neuraxial procedures. References are made to resources that are available for other hospitals in the process of implementing the change to the NRFit system, which should result in the reduction of harm to patients.

Health professionals make mistakes that can have a catastrophic impact on patients, but, as Kohn et al (2000) noted, ‘to err is human’. In the vast majority of cases, human errors are made by well intentioned, highly trained skilled personnel. The onus is on humans to design systems to ensure that patients are safe from accidental injury.

Misconnection or wrong route administration of drugs is an issue that dogs medical practice globally. The consequences of wrong route administration may be fatal instead of merely inconvenient or financially costly. The use of the same luer small-bore connectors, be they accessing the parenteral, enteral, or neuraxial system, has led to a number of ‘serious untoward incidents’ over the years. The International Organization for Standardization (ISO) has been developing specific connectors for each individual route. The first to be seen in UK hospitals, ISO 80369-3:2016 (ISO, 2016a), was the implementation of a unique connector and purple-themed administration system for all oral and enteral products, ENFitTM.

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